Case report: Combined transarterial and direct approaches for embolization of a large mandibular arteriovenous malformation

Abstract

Arteriovenous malformations (AVMs) that involve the mandible are difficult lesions to treat, with traditional options being surgery and embolization. This article describes a large mandibular AVM that was treated with embolization using transarterial as well as direct puncture approaches. Follow-up imaging showed thrombosis of the vascular spaces of the malformation. There were no complications. The patient is doing well and is on follow-up.

Keywords: Arteriovenous malformation; embolization; mandible.

Figure 1

Orthopantomogram shows a large expansile osteolytic lesion (arrows) involving both sides of the body of the mandible

Figure 2

Axial, non-enhanced CT scan shows the expansile and osteolytic nature of the lesion, with hyperdense areas within (arrows) signifying partial thrombosis

Figure 3 (A,B)

Axial (A) and sagittal (B) contrast enhanced T1W MR images show the arteriovenous malformation (AVM) (arrows) involving the whole of the body of the mandible

Figure 4

Lateral DSA image shows venous drainage of the AVM (long arrow) into the left internal jugular vein (short arrow)

Figure 5

Lateral representative DSA image, of the left external carotid artery shows the embolized branch of the lingual artery seen as a glue-cast (straight arrow) and a hypertrophied anterior branch (curved arrow) from the terminal external carotid artery, supplying the AVM.

Figure 6 (A,B)

Frontal (A) and lateral (B) post-embolization radiographs after direct percutaneous glue injection show complete filling of the AVM (arrow) in the mandible with a mixture of N-butyl cyanoacrylate glue and radioopaque contrast agent (Lipiodol)

Figure 7 (A,B)

Post-embolisation T2W axial (A) and coronal (B) MRI images show thrombosis (arrow) of the AVM in the mandible and the absence of flow voids